中医病例讨论中医病例讨论

胃脘痛胃脘痛（中焦阳虚）（中焦阳虚）

一一 .. 辩证导引辩证导引

Today we will discuss the TCM case of a 36-Today we will discuss the TCM case of a 36-

year-old man year-old man 。。

今天我们要讨论的是今天我们要讨论的是 33 ６岁男性中医病６岁男性中医病

例例 ..

二二 .. 病史陈述病史陈述

First of all, I would like to present the case.First of all, I would like to present the case.

首先，我为大家介绍此病例首先，我为大家介绍此病例

二二 .. 病史陈述病史陈述

Today we will discuss the case of a 36-year-old Today we will discuss the case of a 36-year-old

man withman with recurrent epigastric pain for five recurrent epigastric pain for five

monthsmonths ..

今天我们要讨论的是一位近五个月以来今天我们要讨论的是一位近五个月以来上腹疼痛的上腹疼痛的 3636 岁男性病例。岁男性病例。

二二 .. 病史陈述病史陈述 Five months ago,the patient felt epigastric pain.At Five months ago,the patient felt epigastric pain.At

that time,the amylase levels was 349 U per liter. that time,the amylase levels was 349 U per liter. The white-cell count and the results of tests of The white-cell count and the results of tests of liver function were normal.the pain continued,and liver function were normal.the pain continued,and the amylase levels did not return to normalthe amylase levels did not return to normal . .

五个月前五个月前 ,, 病人感到上腹疼痛病人感到上腹疼痛 .. 淀粉酶水平是淀粉酶水平是349349 单位每升单位每升 .. 白细胞数目和肝功能正常白细胞数目和肝功能正常 .. 疼痛疼痛继续继续 .. 淀粉酶水平一直不正常淀粉酶水平一直不正常 ..

二二 .. 病史陈述病史陈述

Twelve weeks ago,he was administration of Twelve weeks ago,he was administration of prednisone(20 mg twice daily). The prednisone(20 mg twice daily). The patient’s pain resolved. The patient had patient’s pain resolved. The patient had lost 5.5 kg in weight during recent weeks.lost 5.5 kg in weight during recent weeks.

1212 周前周前 ,, 病人使用了强的松病人使用了强的松 2020 毫克毫克 ,, 每天两每天两次次 .. 最近几周病人体重下降最近几周病人体重下降 5.55.5 公斤公斤 ..

二二 .. 病史陈述病史陈述 Sixteen weeks before admissionSixteen weeks before admission ，， an an

endoscopic examination showed diffuse endoscopic examination showed diffuse attenuation of the common bile duct and attenuation of the common bile duct and focal narrowing at the origin of the left focal narrowing at the origin of the left hepatic ducthepatic duct

入院前入院前 1616 周周 ,, 内窥镜显示胆管变薄内窥镜显示胆管变薄 ,, 左侧胆管变左侧胆管变狭窄狭窄 . .

二二 .. 病史陈述病史陈述

but the intrahepatic duct s were not but the intrahepatic duct s were not optimally distended . The same day an optimally distended . The same day an upper gastrointestinal endoscopic upper gastrointestinal endoscopic examination showed abnormalities in the examination showed abnormalities in the entire pancreasentire pancreas ，，

但是肝内胆管无扩张但是肝内胆管无扩张 .. 同一天的胃肠内窥镜显同一天的胃肠内窥镜显示胰腺的畸形示胰腺的畸形 ..

二二 .. 病史陈述病史陈述 He had a tendency toward constipation and He had a tendency toward constipation and

urinary frequency.He had had no recent episodes urinary frequency.He had had no recent episodes of nausea,vomiting,or diarrhea.His paternal of nausea,vomiting,or diarrhea.His paternal grandmother had died of “stomach cancer,”but grandmother had died of “stomach cancer,”but there was no family history of pancreatitis.there was no family history of pancreatitis.

最近他有便秘和尿频现象最近他有便秘和尿频现象 .. 没有头晕恶心没有头晕恶心 ,, 呕呕吐吐 ,, 腹泻的现象腹泻的现象 .. 他的曾祖母死于胃癌他的曾祖母死于胃癌 ,, 没有胰没有胰腺炎家族史腺炎家族史 ..

二二 .. 病史陈述病史陈述 Physical examination (Physical examination ( 体格检查体格检查 ) :) : T 36.7 , HR83bpm,BP 115/75 mmHg;Normal ℃T 36.7 , HR83bpm,BP 115/75 mmHg;Normal ℃

development ,normal nourishment ,unpalpation of development ,normal nourishment ,unpalpation of superficial lymph node,normal breath sound of the superficial lymph node,normal breath sound of the lung ,HR 83bpm ,regular. Slightly palpational pain lung ,HR 83bpm ,regular. Slightly palpational pain in epigastric abdomen ,no palpational pain in other in epigastric abdomen ,no palpational pain in other region ,without any reflect pain .No edema in the region ,without any reflect pain .No edema in the low extremities.low extremities.

发育正常，营养良好，浅表淋巴结未及，双肺呼吸音发育正常，营养良好，浅表淋巴结未及，双肺呼吸音正常，心率正常，心率 83 bpm83 bpm ，律齐。中上腹轻压痛， 无反跳痛，，律齐。中上腹轻压痛， 无反跳痛，其余部位无压痛，双下肢无水肿。 其余部位无压痛，双下肢无水肿。

二二 .. 病史陈述病史陈述

InspectionInspection ，， Auscultation and Olfaction, pulse-Auscultation and Olfaction, pulse-feeling and palpation :feeling and palpation :

sallow complexionsallow complexion ， ， fatigue looking , fatigue looking , lassitude , reluctance to speak , emaciation ,lassitude , reluctance to speak , emaciation ,

cold limb aversion to cold ,eyeball without cold limb aversion to cold ,eyeball without icterus. painful express.icterus. painful express.

望、闻、切：面色萎黄望、闻、切：面色萎黄 ,, 神疲乏力，少气懒言，神疲乏力，少气懒言，形寒肢冷，恶寒，无黄睛，苦痛楚楚。形寒肢冷，恶寒，无黄睛，苦痛楚楚。

二二 .. 病史陈述病史陈述 Inquiry : poor appetide ,constipation and urinary Inquiry : poor appetide ,constipation and urinary

frequary , good sleep ,no nausea,vomiting,diarrheafrequary , good sleep ,no nausea,vomiting,diarrhea.. 问诊：胃纳不馨，大便闭塞，小便清长，夜寐尚安。无问诊：胃纳不馨，大便闭塞，小便清长，夜寐尚安。无

恶心、呕吐、腹泻等症。恶心、呕吐、腹泻等症。 Picture of the tongue : whitish enlarged tang with slight Picture of the tongue : whitish enlarged tang with slight

yellow fur in center .yellow fur in center . 舌象：淡白胖大舌，中有薄黄苔舌象：淡白胖大舌，中有薄黄苔 Pulse -taking: Thin ,weakPulse -taking: Thin ,weak 脉象：细 弱脉象：细 弱

三三 .. 病证要点病证要点

epigestric painepigestric pain 胃脘痛胃脘痛

四四 .. 中医辨证中医辨证 Epigastric pain is a chronic persist ache in the Epigastric pain is a chronic persist ache in the

upper abdomen. It can be caused by Qi upper abdomen. It can be caused by Qi asthemia ,pathogenic cold invasion and blood asthemia ,pathogenic cold invasion and blood stasisstasis ，， etc.etc.

胃脘痛是中上腹的慢性持续性疼痛，可以因为胃脘痛是中上腹的慢性持续性疼痛，可以因为气虚、外寒入侵或是血瘀等引起。气虚、外寒入侵或是血瘀等引起。

四四 .. 中医辨证中医辨证 It is not likely the dianosis of heart-ache. It is not likely the dianosis of heart-ache.

Because it usually companied with a series of Because it usually companied with a series of cardiac sympotoms like irregular heart rate, cardiac sympotoms like irregular heart rate, short breath, palpitation , cardialgia .So heart short breath, palpitation , cardialgia .So heart disease is an unlikely disease in this case.disease is an unlikely disease in this case.

鉴别诊断：真心痛：可有一系列心脏的症状伴鉴别诊断：真心痛：可有一系列心脏的症状伴随随 ,, 如：心律失常、 短气、心悸、心痛等。本如：心律失常、 短气、心悸、心痛等。本病程中无任何上述伴随症状出现，基本可以排病程中无任何上述伴随症状出现，基本可以排除心脏病。除心脏病。

五五 .. 病机分析病机分析

It is because of insufficiency gastroplenic It is because of insufficiency gastroplenic Yang .Asthenic Yang cause endogenous cold Yang .Asthenic Yang cause endogenous cold (said Nei Jing) ,coldness leads to ache .And the (said Nei Jing) ,coldness leads to ache .And the tongue and the pulse also suggest the diagnosis.tongue and the pulse also suggest the diagnosis.

本证主要因中焦阳气不足引起。本证主要因中焦阳气不足引起。《《内经内经》》云“阳云“阳虚则寒”，寒主痛，故中焦阳气不足而见胃脘痛。虚则寒”，寒主痛，故中焦阳气不足而见胃脘痛。舌脉亦见阳气虚损症状。舌脉亦见阳气虚损症状。

六六 .. 中医诊断中医诊断

Diagnosis of TCM: epigestric pain Diagnosis of TCM: epigestric pain (insufficiency of gastrolenic Qi) (insufficiency of gastrolenic Qi)

入院中医诊断：胃脘痛（中焦阳虚） 入院中医诊断：胃脘痛（中焦阳虚）

七七 .. 治疗原则治疗原则

Principle : invigorating Yang Principle : invigorating Yang ，， worming the worming the stomach to liminate cold stomach to liminate cold

治则：温阳健脾，温中散寒治则：温阳健脾，温中散寒

八八 .. 方剂选择方剂选择

Prescription : Pegulating the Middle Prescription : Pegulating the Middle Decoction & Rour –Noble Drug Decoction Decoction & Rour –Noble Drug Decoction

方剂：理中汤（方剂：理中汤（《《伤寒论伤寒论》》）合四君子汤）合四君子汤《《圣圣济总录济总录》》